Clinical Rehabilitation 2002; 16: 368377

Hypnotic imagery as a treatment for phantom

limb pain: two case reports and a review
David A Oakley Department of Psychology, University College London, Lionel Gracey Whitman Leeds General
Inrmary, Leeds and Peter W Halligan School of Psychology, University of Cardiff, UK
Received 18th August 2000; returned for revisions 20th November 2000; revised manuscript accepted 3rd April 2001.

Objective: To provide a theoretical background, to review existing literature

and to present new case material relevant to the treatment of phantom limb
pain using hypnotic imagery.
Method: This paper presents two new case reports involving the use of
hypnotic imagery procedures in the alleviation of phantom limb pain and
reviews 10 previous clinical studies which have involved a similar approach.
The earlier studies were identied by electronic and manual searches of the
relevant literature.
Results: Two main treatment strategies can be identied: (1) ipsative/
imagery-based approaches and (2) movement/imagery-based approaches.
A common nding is the need to treat the phantom limb as a real body
part, to accept its existence as a valid mental representation and to avoid
treating the amputation stump as the sole source of the phantom pain
sensations.
Conclusion: Hypnotic procedures appear to be a useful adjunct to established
strategies for the treatment of phantom limb pain and would repay further,
more systematic, investigation. Suggestions are provided as to the factors
which should be considered for a more systematic research programme.

Introduction
Traditionally, phantom limbs (i.e. residual, nonvisual experiences of the affected body part) have
been reported following limb amputation1 and
brachial plexus avulsions,2 though similar phenomena also occur after mastectomy3 and
removal of a variety of other body parts and
internal organs as well as following stroke.4 PostAddress for correspondence: David Oakley, Hypnosis Unit,
Department of Psychology (Remax House), University
College London, Gower Street, London WC1E 6BT, UK.
e-mail: oakley@the-croft.demon.co.uk
Arnold 2002

surgically the majority of amputees (between 50

and 85% according to Jensen et al.5) develop pain
that they attribute to the phantom limb itself
(phantom limb pain: PLP). The qualitative experience of PLP is very variable between individuals, and includes sensations of burning, cramping,
stabbing and clenching spasms.6
Different accounts have been put forward to
explain this debilitating phenomenon.6 One view
is that PLP represents a continuation, or memory, of normally transduced pain which was present prior to the amputation.7 Other accounts for
the origin of the pain include the release of spinal
cord neurons from inhibition following loss of
10.1191/0269215502cr507oa

Hypnosis and phantom limb pain

afferent impulses8 and the reorganization of cortical maps following limb amputation.9,10 The
view that phantom limb pain is accompanied by
remapping of cortical areas has received recent
empirical support from clinical11 and neurophysiological studies.12 There is also neuroimaging
evidence that phantom limb sensations, including
PLP, are accompanied by activity in the same
brain areas as when the body is intact.13
Even when present, the phantom experience is
not static and several factors such as emotion,
weather change, eating and fatigue can affect
PLP.6 There is also evidence that the nature of
the phantom limb experience may be inuenced
by suggestion and expectation (e.g. refs 11 and
14).
The results achieved with PLP from surgical
and pharmacological treatments are generally
reported to be poor1517 though there is evidence
that psychological interventions are more effective.18 To the extent that PLP is variable and may
correspond with past experience, current beliefs,
expectations and fantasies one possible approach
to its management may be via imagery and suggestion. This may be particularly effective if hypnosis is used as an adjunct to treatment,19 as
hypnosis procedures encourage focused attention
and facilitate absorption in central imaginative
processes.
Furthermore, hypnotic procedures using suggestion and imagery have a long and established
history of alleviating a range of painful conditions 2022 and recent brain-imaging studies have
shown that changes in the subjective experience
of pain produced by suggestions given in hypnosis are reected in alterations in the activation of
brain areas known to be involved in normal pain
perception.13,23
No systematic research appears to have been
carried out either to evaluate the effectiveness of
hypnosis as an adjunct to the treatment of PLP
or to determine the types of treatment with
which hypnosis might be most effectively
employed. There are, however, a number of single-case studies where hypnosis has been used
with PLP and these provide useful insights into
possible treatment strategies. We propose here
that two basic treatment approaches can be identied: (1) ipsative/imagery-based and (2) movement/imagery-based.

369

The ipsative/imagery approach takes account

of the way the individual represents their pain to
themselves and then attempts to modify those
representations in order to alleviate the pain
experience. The movement/imagery-based approach encourages the PLP patient in hypnosis
to move the phantom limb and to take control
over it.
We rst of all describe two previously unpublished cases of our own and then present in the
form of a table a review of ten other single-case
studies in which hypnosis was used in the treatment of PLP classied according to the two treatment approaches we have identied.
Previously unpublished case reports
Mrs D Application of an ipsative/imagery
approach
Mrs D is a 76-year-old woman with a history
of peripheral vascular disease that eventually led
to an above-knee amputation of her right leg. It
is worth noting that Mrs D was pain-free at the
time of her operation and that her PLP did not
begin until some two years after the amputation;
two years after that she was referred to a local
pain clinic. There were four different components
to the pains in her missing lower limb:
1) pins and needles in her foot,
2) her toes felt as thought they were being held
in a tight vice,
3) a slicing, cutting pain in the sole of her foot
and
4) a chiselling pain in her ankle.
Over the next four years various treatments
were tried, including injection of the stump with
local anaesthetic, acupuncture, the use of a TENS
(transcutaneous electrical nerve stimulation)
machine, antidepressants and analgesics, including morphine, with little or no effect. Mrs D was
then seen eight times on a weekly basis for onehour counselling sessions, with approximately 25
minutes of each session being taken up with hypnosis.
Mrs D responded well to the hypnotic procedures that were introduced in the rst treatment
session. A modied Spiegel eye-roll24 was used
for induction, followed by progressive muscular

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DA Oakley et al.

relaxation for deepening. This was followed by

suggestions of visualization of a special place.
Her choice of Italy as her special place suggested
imagery which might be used for the chiselling
sensation in her phantom ankle, which she
ranked as the most disturbing of her pains.
At the second session she was asked in hypnosis to return to her special place, to imagine
Michaelangelo toiling and hammering away at a
block of marble with a chisel to create a thing of
lasting beauty. At the third session, the image of
the sculptor was related to the pains in her ankle:
Just as Michaelangelo sculpted David, imagine a
little man with a chisel hammering away at your
ankle. It was then suggested that this man has
been working so long and so hard and his work
is done and it is time for him to go away on holiday. Though she had initially found the little
man and his specic activities difcult to visualize, Mrs D later announced that the chiselling
pain in her ankle had, in fact, completely gone.
The disappearance of the pain had coincided with
sending [him] off on holiday.
Sessions 4 and 5 incorporated more general
images of change and progress without any further specic pain-control imagery. Over this time
Mrs D experienced a marked improvement in her
mood but her other pains remained. She commented that the vice-like pain had become more
noticeable since the chiselling pain had gone.
Pressures on the hypnosis clinic were such that
Mrs D was only able to have two more sessions
and the nal two sessions concentrated on the
vice-like pain. In these sessions she was asked to
imagine wading in the sea, with the tides loosening the vice around her toes. This image appears
to have been a much less effective one for
Mrs D.
Contacting Mrs D three months after the end
of her treatment, she reported that the the chiselling pain had not come back. The little fellow,
she wrote, is having a long holiday. Thank goodness! The toes are still in a vice but I am coping
and I am not quite as jumpy as I was.
NB Application of a movement/imagery
approach
Our second case is a report of observations carried out with NB, a 46-year-old man who had
experienced PLP since he suffered an avulsion of

his left brachial plexus some ve years previously.

He describes two types of PLP. The rst is an
intense cramp-like experience in his denervated
left arm which occurs intermittently, approximately once per day, and lasts for 20 minutes.
During this pain he feels his left hand become
clenched and he experiences a burning sensation.
The second type of pain occurs more frequently,
every two to three minutes, is like small electric
shocks which shoot down from his upper arm
and terminate in the little nger of his phantom
left hand, and is accompanied by a throbbing sensation in the knuckles.
NB had previously used a Ramachandran mirror apparatus10 which prevented him from seeing
his right hand directly but allowed him to see it
as a reection where his left hand would be. He
reported experiencing the reected image as that
of his phantom left hand, which he described as
moving normally when he moved his right hand.
Whilst viewing the mirror image both types of
PLP disappeared. When NB closed his eyes the
sensation of moving his left hand was lost, even
though he continued to move his right hand as
before. NB had used the mirror apparatus at
home on a daily basis and he reported that his
pains could be reduced for up to three hours
afterwards. When he was tested by us in the clinic
he rated his PLP as 7 out of 10 before the mirror test, during the mirror viewing test it was 0,
and immediately afterwards it was 2.
One hour after testing with the mirror apparatus NBs pain had reached 4 and he was then
taken through an eyes-closed hypnotic induction
and deepening. He was asked to place his right
hand in the (now removed) mirror apparatus and
to see his reected right hand in the left of the
mirror as usual. In reality his eyes were closed
throughout but he made real movements with his
right hand. He said he could see his left hand
clearly and was asked to try to move both hands
in synchrony. He reported that he felt his left
hand moving though the feeling was not as
strong as usual in the mirror apparatus. With further encouragement to watch closely the hand in
the mirror while he continued to make (actual)
movements of his right hand, he reported that the
sensation of movement in his left hand became
clearer, though he said it was still not as strong
as usual. Nevertheless he did report freedom

Hypnosis and phantom limb pain

from pain in his phantom left arm and hand (a
rating of 0 out of 10) as he watched the mirror
hand moving. Shortly after the end of the hypnosis session NB rated his pain at 2.5 on the 10point scale.
These tests with NB were not carried out as
part of a therapeutic intervention and consequently he was not instructed in how to use the
techniques for his own pain control and no information is available on any long-term effect they
may have had. They do however, support the
view that movement/imagery-based strategies in
hypnosis might be used in the treatment of PLP.
Initially they might be employed for alleviating
PLP during self-hypnosis routines but ultimately
the therapeutic aim would be to extend the effect
into everyday situations.
Review
We have limited our review of PLP to cases
involving limb amputation and brachial plexus
avulsion as these are the most common causes.
In preparing the review, seven reports were identied electronically via Ovid/MEDLINE using
hypnosis and phantom as the target and searching keywords, abstract and heading word from
1966 to the present. Of these, three were
excluded: Two because they concerned other
phantom organs25,26 and one because it was insufciently detailed to classify in terms of the hypnotic procedures used.14 One report not identied by this search27 is included in the review and
was identied again via Ovid/MEDLINE by
using phantom limb from 1966 to the present as
the target (661 citations). A manual search of private and institutional libraries in London under
the headings hypnosis and hypnotherapy
yielded six additional reports; three as parts of
chapters in edited volumes, two in very recent
issues of journals, and one in a single-author text
book. One of these28 was not used in the review
as it contained insufcient detail. Salient points
from all of the reports excluded from the review
are included in the Discussion section.
A structured summary of the remaining 10 previously published cases using hypnosis in the
treatment of PLP plus the two new cases
reported here is shown in Table 1.

371

Table 1 summarizes ve cases (plus our case

Mrs D) in which a ipsative/imagery-based
approach was used and a further ve cases (plus
our case NB) where a movement/imagery-base
approach was involved.
Discussion and conclusions
Two main treatment strategies for PLP have
been identied: an ipsative/imagery-based
approach and a movement/imagery-based
approach. Both appear to have promise though
there is insufcient evidence to say which is likely
to be the more effective for any given patient or
whether they should be administered singly, in
combination or perhaps at different stages of
treatment. It is possible, however, that a movement/imagery-based approach would be particularly relevant where a cramped or unusual
posture of the phantom is an important component of the patients description of their PLP. Of
the six cases using an ipsative/imagery approach
reported in Table 1 only two included posture of
the limb as part of the PLP description, whereas
it was present in ve of the six cases which
adopted a movement/imagery based.
Shrinking of the phantom occurred spontaneously in one case (case 1036) and in response
to suggestion in two cases (case 331 and case 734).
In common with some mirror box studies 36 this
appeared to be associated with recovery from
PLP. In another of the case reports (case 5 33)
indirect suggestions for phantom shrinkage were
used, though the effectiveness of these sugges-

Clinical messages
Phantom limbs should be regarded as real
body parts and treatment of phantom limb
pain (PLP) should be directed to the phantom itself.
Hypnotic imagery-based approaches are
worthy of further consideration for the
treatment of PLP.
The imagery used should be based on the
clients own perception of their pain or may
involve movement of the missing limb.

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DA Oakley et al.

Table 1 Summary of 12 cases using ipsative/imagery-based approaches (cases 16) or movement/imagery-based

approaches (cases 712)
Case
Ipsative/imagery-based
1) Siegel (1979)29

Problem

Treatment

Outcome

Left above-knee
amputation (pain
before)

10 sessions
(7 of hypnosis).
Relaxation, selfhypnosis, transfer of
hypnotic (cold
imagery) glove
anaesthesia

2 months after
treatment, patient
using pain control
for herself

3 hypnosis sessions.
Relaxation, tension
reduction
suggestions.
Warmth imagery.
Home use of
hypnosis audiotape

Free of PLP over 5year follow-up

Number of sessions
not specied.
In hypnosis
relaxation &
suggestions of
phantom shrinking.
Hypnotic images:
decapitate ants,
cut bands.
Daily use of
hypnosis audiotape

At end of therapy
discomfort down to
30% of previous
level

21 sessions over 8
weeks. Selfhypnosis relaxation
training plus
imagery of
beach/garden/
woods.
Healing warmth
owing through arm.
Positive, futureoriented
suggestions

At 2-week followup, pain under

control. No longer
interfering with daily
activity. Returned
to work

Three sessions (5
hours in total)

At 12 month followup wearing

prosthesis and
engaging in
mountain biking

PLP for several

weeks nature of
pain not described
2)

Chaves (1986)30

Amputation of arm
(pain before)
PLP for 5 months felt
as tension and
frustrated
movement in hand
& ngers
(hand/arm in
uncomfortable
posture)

3)

Chaves (1993)31

Mid-thigh
amputation of right
leg (pain before)
PLP for 4 years felt
as
a) biting ants,
b) tight bands
c) muscle tension
(leg in
uncomfortable
posture)

4)

Sthalekar
(1993)32

Avulsion of right
brachial plexus (no
pain before)
PLP for 3.5 months
felt as constant
tingling in right
arm and
intermittent
localized stabbing,
burning pains in
arm and hand

5)

Brown et al.
(1996)33

Amputation of right
leg at the knee
(pain status before
not reported)
Details of PLP not
reported, but
severe

Hypnotic metaphor
or tree damaged by
ood water, losing
branches, then
regrowing stronger

Pain medication
reduced to 50%

Using tape once per

month

Occasionally
pain-free
Phantom reported to
be shrinking

Right arm no longer

in a sling
Optimistic about
future

No report of pain
status

Hypnosis and phantom limb pain

6)

Mrs D

Movement/imagery-based
7) Muraoka et al.
(1996)34

8)

Le Baron and
Zeltzer (1996)35

Above-knee
amputation of right
leg (no pain before)

8 weekly sessions of
1 hour (25 mins of
each was hypnosis)

PLP for 6 years

began 2 years after
amputation, felt as:
a) pins and needles
in foot,
b) toes in a vice
c) cutting pain in
foot
d) chiselling pain in ankle

Hypnotic imagery:
chiseller on
holiday,
sea water loosening
vice

Above-knee
amputation of left
leg (no pain before)

64 hypnosis
sessions over 3
years.

PLP for 25 years felt

as intermittent
burning pain and
constant dull pain
(leg & foot in
uncomfortable posture
and leg too short)

3 phases:
a & b) suggested
movements of leg
and becoming
normal size
c) suggested
shrinking of phantom

Amputation of left
leg (pain status
before not reported)

3 hypnosis sessions.
Relaxation,
suggestion in
hypnosis to relax
and contract
muscles in both
legs.
Patient experienced
free movement in
toes and leg.
Transfer of suggested
numbness in hand
to left leg

At 2-week followup 50100% pain

relief from selfsuggestion, or by
listening to hypnosis
audiotape.
Less bothered by
residual PLP &
sleeping normally

Hypnosis for part of

rehabilitation
programme
number of sessions
not specied.
Relaxation &
hypnotic
suggestions for
nger movement
and uncramping

Reduction in PLP
(not quantied)

PLP felt as jerking

in leg, cracking in
toes, stabbing pain
in sole of foot
Highly hypnotizable

9)

Ersland et al.
(1996)27

Above-elbow
amputation of right
arm (pain status
before not reported).
PLP for 18 months in
ngers and wrist
(ngers and wrist
in uncomfortable
posture)

10) & 11) Rosen et al.

(2000)36

373

Coping better and

less jumpy

Positive images of
change and progress

10) Traumatic
amputation of right
arm (no pain before)
PLP for 5 years.
Radiating heat pain
in arm & ngers.
Abnormal
posture/contraction
in ngers and arm.
arm. Highly hypnotizable

At end of treatment
chiselling pain had
gone and had not
returned at 3-month
follow-up. Other
pains still there

Both 10 & 11:

Approx. 12 sessions
over 6 months
Cognitive/behavioural
treatment with
hypnosis

At end of treatment
phantom had
disappeared for most
of time with
intermittent bursts
of pain. Overall
pain had been
reduced from 8 to 1
on a scale 010

Feeling of control
made residual pain
more tolerable

10) Pain-free during

1st hypnosis session
lasted 1 day then
pain returned
intermittently. At
end of treatment
pain intensity down
from 80 to 50
Pain frequency
reduced by 55%

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DA Oakley et al.

Table 1

Continued

Case

Problem

Treatment

11) Traumatic
amputation of
ngers on left hand
(no pain before)

In hypnosis
imagined phantom
in a comfortable
position or moving
in a comfortable
way

PLP for 3 years

12)

NB

Severe pain in left

hand, cutting pain
in ngers,
especially during
uncomfortable
movements.
Moderately
hypnotizable

10) Also imagined

skiing, both arms
moving in rhythm

Avulsion of left
brachial plexus (no
pain before)

Previous experience
of pain control and
subjective
movement of left
hand in mirror
apparatus

PLP for 5 years felt

as intermittent
cramping in hand
and burning
sensation.
More frequent
shooting pains
through arm &
throbbing in
knuckles
(hand in
uncomfortable
clenched posture)

tions is not reported. These observations suggest

a third possible therapeutic approach in which
hypnotic imagery may be a useful adjunct.
In more general terms it seems that the phantom limb should be treated as real and the same
pain management strategies applied as with a
physically present limb. The reality of the missing limb as a continuing central representation is
underlined by recent neuroimaging studies showing activations in precentral cortex during phantom nger tapping27 and the involvement of
normally activated brain areas during the experience of both phantom limb movement and PLP.13
In our own case of Mrs D and also in case 1 30 the
patients specically said that they expected psychological treatment of PLP to be directed

11) Also imagined

pain area shrinking

One session of
hypnosis with
suggestions of a
return to the
mirror experience
and of ageregression to a time
before the injury

Outcome
Phantom reported to
be shrinking
11) At end of
treatment pain
intensity was down
from 40 to 20 and
pain frequency
reduced by 50%
These gains
maintained at 2.5
years follow-up

During experience
of moving left hand
in hypnotic virtual
mirror and during
age-regression PLP
was lost.
Experience of left
hand movement not
as strong as in real
mirror apparatus
Pain was rated 4 out
of 10 before
hypnosis, 0 during
hypnotic mirror and
regression
experiences and 2.5
after hypnosis

towards their phantom limb and not to the amputation stump. Similarly, in one study,28 hypnotic
glove anaesthesia applied to the stump produced
only a temporary alleviation of the burning
PLP; a later suggestion to visualize a stream of
cooling anaesthetic agent coursing through the
phantom leg produced long-term pain reduction.
Closely related to the movement/imagerybased approaches, the Ramachandran mirror
procedure appears to produce a dramatic, but
short-lived, effect of experiencing movement in
the missing limb and of eliminating PLP.10 Our
own observations with NB indicate that it is possible to create a similar effect using a hypnotically suggested hallucination of a mirror in a
patient with previous experience of the mirror

Hypnosis and phantom limb pain

apparatus. It remains to be seen if a similar effect
could be produced in a mirror-naive patient. For
NB the hypnotic mirror effect was less powerful
than that produced by the actual mirror so far as
the subjective experience of movement in the
missing limb was concerned. This may mean that
actual peripheral visual feedback of limb movement is more effective in this regard than selfgenerated
feedback
through
imagery.
Nevertheless the elimination of PLP by the hypnotic, virtual mirror seems to have been similar
to that achieved using the actual mirror. A major
potential advantage of the hypnotically produced
mirror is that patients could recreate the imagery
themselves and use it on a continuous basis for
pain relief. The fact that the experience of movement was not as striking for our patient using the
hypnotic mirror compared to the actual mirror
whilst the PLP reduction effect was maintained
may mean that he was experiencing indirectly
suggested pain reduction based on his prior experience and expectations rather than it being
attributable to subjective movement in his phantom limb.
Whilst they have been helpful in thinking
about different approaches to the problem of
PLP, the cases reviewed here (including our own)
have a number of shortcomings which need to be
addressed in future studies. A major problem is
that of the small numbers of patients involved
and consequently there is a need for randomized
control trials with well-dened (and clearly
reported) hypnosis and treatment protocols to
evaluate the efcacy of the various approaches
which have been suggested. There is also a need
for standardized measures of the PLP to be taken
pre and post intervention along with other measures of psychological and social adjustment.
Also, hypnotizability was measured in only three
of the cases reviewed here (case 8,35 case 1036 and
case 1136). It is perhaps signicant that in two of
these three cases hypnotizability was found to be
high. This is potentially an important issue in
selecting patients for hypnosis-based PLP treatment as a recent meta-analysis has shown greater
hypno-analgesic effects in those moderate to high
in suggestibilty compared with those scoring low
on hypnotizability.21
Equally, it is important to determine the role
of hypnosis per se in the outcomes achieved in

375

systematic trials with appropriate controls for the

hypnotic procedure. Particularly in the case of
ipsative/imagery-based strategies it will be informative to investigate the relationship between
specic suggestions or images and the alleviation
of particular types of pain. In our own case (Mrs
D), for instance one of the images (for the chiselling pain) appeared to be much more effective
for her than the other (for the vice-like pain)
and it may be important to encourage the patient
to supply his/her own imagery rather than it originating with the therapist. One way of investigating the specicity of the effects of imagery would
be to use a multiple baseline, single-case
approach with different pain types being targeted
sequentially. A similar question for the movement/imagery-based approach concerns the
modality of the suggested imagery in relation to
outcome. In our own case (NB), we encouraged
visual as well as kinaesthetic and somaesthetic
feedback from the moving limb. In the other
movement/imagery cases the type of imagery
employed was not clearly specied but seems to
have been primarily proprioceptive, though in
one case (case 8)35 the patient was also asked to
visualize his leg.
We conclude that, despite the relative paucity
of published reports, hypnotic procedures hold
the promise of being an effective adjunct to other
strategies for the treatment of PLP and other
phantom body part conditions and would repay
further, more systematic, investigation. Hilgard
and LeBaron38 selected PLP to illustrate the
research opportunities which exist in the area of
hypnosis and persistent pain. It is unfortunate
that some 15 years later these opportunities still
do not appear to have been explored.
Acknowledgements
LG-W was employed by Friarage Hospital,
Northallerton Yorkshire, UK during the time
that the clinical data reported here were collected. PWH is supported by the Medical
Research Council.
We are grateful to Mrs D and NB for their cooperation as participants in our own case studies
which we report here and to Derick T Wade and
two anonymous referees for their helpful comments on an earlier version of this paper.

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DA Oakley et al.

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